Amid COVID-19 overload, Alaska's largest hospital is now prioritizing care under crisis standards - Anchorage Daily News

A sign points to the emergency department at Providence Alaska Medical Center, photographed on Wednesday, Aug. 11, 2021 in Anchorage. (Loren Holmes / ADN)

Alaska’s largest hospital is now implementing crisis standards and rationing medical care amid a crush of COVID-19 patients and staff shortages that have forced providers to prioritize patients most likely to recover.

Providence Alaska Medical Center’s chief of staff announced the decision in a two-page letter Tuesday that urges Alaskans to wear masks regardless of their vaccination status, get tested, get vaccinated if eligible and avoid potentially dangerous activities or situations that could result in hospitalization.

More than 30% of the adults hospitalized at Providence were COVID-positive as of Tuesday. Patients with the virus demand more time-consuming care than most others, providers say.

“The acuity and number of patients now exceeds our resources and our ability to staff beds with skilled caregivers, like nurses and respiratory therapists,” states the letter, signed by Providence Chief of Staff Dr. Kristen Solana Walkinshaw on behalf of the hospital’s medical executive committee, more than 1,000 doctors, nurse practitioners and physician assistants. “We have been forced within our hospital to implement crisis standards of care.”

The policy was enacted over the weekend.

Hospitals around the state report operating at or near capacity, with very limited options for transferring patients to Seattle or other Lower 48 hospitals that usually provide care for patients from Alaska.

Gov. Mike Dunleavy on Tuesday urged more Alaskans to get vaccinated against COVID-19 as the highly infectious delta variant continues to drive a meteoric wave of new cases and hospitalizations at some of the highest levels in the country. The state on Tuesday reported seven more deaths linked to the virus, near-record hospitalizations and nearly 700 new cases.

“We’re out of beds. Life saving measures are not going to be possible in every case,” said Dr. Leslie Gonsette, an internal medicine hospitalist and member of Providence’s executive committee board who helped draft the letter. “And that’s what we’re trying to emphasize.”

Dr. Leslie Gonsette, an internal medicine hospitalist at Providence Alaska Medical Center, testifies during the Anchorage Assembly meeting on Tuesday, Sept. 14, 2021. Donna Mears, Vice Chair of Anchorage's Health and Human Services Commission, is at right. (Bill Roth / ADN)

Last year, Anchorage enacted strict COVID-19 mitigation measures including mandatory masking and capacity restrictions under prior administrations. Anchorage Mayor Dave Bronson has made it clear he opposes such requirements.

‘We are in a crisis at the hospital’

At least 30 physicians and other health care workers, including Solana Walkinshaw and Gonsette, attended the Anchorage Assembly meeting Tuesday evening. They were praised by some Assembly members and grilled by others. They were occasionally interrupted by murmurs of disagreement and discontent from others in the crowd.

Bronson praised the municipality’s work on testing and monoclonal antibody treatment sites and reiterated his opposition to any vaccine requirements as the meeting got underway. Several people testified in opposition to vaccination and other mitigation policies. At least one suggested the virus was nothing to be afraid of.

“We are in a crisis at the hospital,” Solana Walkinshaw testified, meaning care had to be rationed. “That means when we have four patients and two machines, two people are not getting that care. It’s happening now.”

Providence Alaska Medical Center staff stand in support during public testimony at the Anchorage Assembly meeting on Tuesday, Sept. 14, 2021. (Bill Roth / ADN)

Gonsette said as she walked into the meeting, she was trying to find an intensive-care bed for a patient in critical condition.

“’My patient is going to probably die. I need an ICU bed,’” she told doctors on the ICU. “And the answer I got was, ‘We are doing our best. We do not have a bed.’ This is what is happening every day. But ... this person doesn’t even have COVID. This person is vaccinated.”

(Video above: Dr. Leslie Gonsette, an internal medicine hospitalist at Providence Alaska Medical Center, speaks to members of the Anchorage Assembly.)

Hospitalist Dr. Ryan Webb called a nursing supervisor while waiting in line to testify after Assembly member Jamie Allard pressed for more information about how many Providence beds are staffed versus unstaffed.

Out of 223 adult beds at Providence, two are unstaffed and one more is temporarily out of service because of a leak, Webb said. The rest are staffed. The hospital as of Tuesday evening had 10 people waiting in the emergency room for a bed, including three waiting for an ICU bed — with none available, he said.

“I would just briefly respond to this suggestion that we should not be afraid,” he said. “I would say that we are terrified as physicians and nurses. What we’re terrified of is being faced with two or three or four patients, and not having the resources that we need to take care of them.”

Dr. Elizabeth Pietralczyk, an Anchorage resident who practices family medicine and spent 18 years in the U.S. Air Force, testified with her voice shaking before beginning to cry. She listed her worries: contracting COVID-19 and leaving her children without a mother, bringing the virus home to her unvaccinated 6-year-old, not being able to get hospital care if a family member is hurt in an accident.

“I worry that I’ll be unable to properly care for my patients and I’ll have to watch them die due to a lack of resources. I have only had to worry about that one other time during remote deployments. I never imagined that I would have to experience that helplessness here at home,” Pietralczyk said. “I have always served my country and my community for my entire adult life. Now I need your help.”

(Video above: Dr. Elizabeth Pietralczyk speaks to members of the Anchorage Assembly during public comment on Tuesday, Sept. 14, 2021.)

The Providence letter describes an emergency room overflowing with patients waiting in their cars for hours and heart attack patients sometimes denied timely life-saving care. Providence now often declines transfer requests from outlying rural hospitals trying to move accident or stroke victims and has instituted strict visitor restrictions.

Some elective procedures, a category that can include tumor removals or heart valve replacements, have been delayed for months and continue to be postponed.

“People from around Alaska depend on Providence to provide medical care for people statewide. Unfortunately we are unable to continue to meet this need; we no longer have the staff, the space, or the beds,” Solana Walkinshaw wrote.

If people need specialty care at Providence — from a cardiologist, trauma surgeon or neurosurgeon — “we sadly may not have room now. There are no more staffed beds left.”

‘Nurses here are not leaving because of the vaccine mandates’

Given Alaska’s still-rising case rates, it’s likely COVID-19 hospitalizations will escalate in the next two to four weeks unless something changes, she wrote.

[Nowhere to go: Rural hospitals struggle to transfer patients as Alaska’s COVID-19 hospitalizations hit new high]

Alaska Regional Hospital is not in crisis-care mode, spokesperson Kjerstin Lastufka said. But the hospital on Tuesday decided to modify the surgery schedule and “prioritize the most critical cases,” Lastufka wrote in an email. “These plans may include rescheduling or postponing certain procedures based on the urgency of the procedure, the judgement of our physician partners, and the current circumstances within our facility and community.”

Dunleavy allowed the state’s COVID-19 emergency declaration to expire in April and last week declined to declare another, instead submitting bills to restore lost telehealth options and streamline health-care worker background checks. The legislation died in the Alaska House after it lost support when a Sunday-night vote added an amendment that could have prevented hospitals from limiting patient visits.

Bronson last week said he will not ask residents to get vaccinated, issue a mask mandate or order other COVID-19 restrictions. Bronson also said hospital capacity issues weren’t caused by COVID-19 patients but nurses leaving their jobs over vaccination requirements.

“Nurses here are not leaving because of the vaccine mandates. They’re leaving because they’re overwhelmed by the emotional toll it’s taking,” Gonsette, the Providence hospitalist, said in an interview Tuesday. “Part of it, we all feel it, is because we are not heard. The public either wants to bury their head in the sand or maybe some of them really don’t know what’s going on. Those are the ones we’re trying to reach.”

The shift to crisis standards means the hospital must “prioritize scarce resources and treatments to those patients who have the potential to benefit most,” the letter states. That means enacting policies and procedures to ration care and treatments, including dialysis and specialized ventilatory support.

The hospital developed its crisis standards of care at the start of the pandemic in March 2020, according to Gonsette. Last week, Providence stood up a triage ethics committee to help physicians facing “difficult decisions,” she said. The executive committee board decided to issue the letter during an emergency meeting Sunday.

Rationing care does not mean denying care for unvaccinated people, Gonsette said. Rather, it involves decisions based on where limited resources go and who benefits the most.

Providence issued a statement Tuesday after the letter surfaced, saying “the current demands on acute care in our hospital and in the state of Alaska are exceeding available capacity and are requiring difficult choices regarding allocation of specific life-sustaining treatments or resources and regarding patient transfers to higher levels of care. As a result of this situation, providers and health care facilities are currently experiencing limitations in their ability to provide the standard of care that we wish to provide to our community and normally expect to provide. This situation may persist for some time, which has required us to use processes developed to ensure the most equitable allocation of limited resources.”

Idaho public health leaders announced last week that they activated crisis standards of care allowing health care rationing for the state’s northern hospitals because there are more coronavirus patients than the institutions can handle.

State health officials last week said they were talking with hospitals about what resources they needed as well as other states, including Idaho.

Daily News photojournalist Emily Mesner contributed reporting.

Read the Providence letter:

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